Health

Group Health Insurance Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Company Name

Street Address

City

State

* Zip Code

What is your position?

* Email Address

Phone Number

Alternate Telephone

Fax Number

Best time to call?

Does your company currently have an insurance carrier?

Yes

No

If so, name of current carrier

Anniversary Date of current plan

Total Number of Employees

Number of Employees to be Insured

Are premiums paid by your company for employee only or spouse too?

Employee Only

Employee and Spouse

Current coverage is for:

Current rate for coverage is:

Please list the companies you would like quoted:

What type of plan do you want compared?

HMO Plan

Dual Options (PPO/POS)

Please choose from the following co-payments:

Would you like a Prescription Plan?

Yes

No

Please choose a deductible:

Please select from the following co-insurances:

What do you like or dislike about your current plan?

Additional remarks or requests

Before submitting, type in required validation security code: jn68g7

Census

Company Name

State

City

Zip Code

Number Of Employees

Employee Data

Employee 1

Zip Code

Employee Name

Birth Date

Gender

Male

Female

Smoker

No

Yes

Spouse

Birth Date

Gender

Male

Female

Smoker

No

Yes

Child(ren)

Child 1 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 2 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 3 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 4 Birth Date

Gender

Male

Female

Smoker

No

Yes

Employee 2

Zip Code

Employee Name

Birth Date

Gender

Male

Female

Smoker

No

Yes

Spouse

Birth Date

Gender

Male

Female

Smoker

No

Yes

Child(ren)

Child 1 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 2 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 3 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 4 Birth Date

Gender

Male

Female

Smoker

No

Yes

Employee 3

Zip Code

Employee Name

Birth Date

Gender

Male

Female

Smoker

No

Yes

Spouse

Birth Date

Gender

Male

Female

Smoker

No

Yes

Child(ren)

Child 1 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 2 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 3 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 4 Birth Date

Gender

Male

Female

Smoker

No

Yes

Employee 4

Zip Code

Employee Name

Birth Date

Gender

Male

Female

Smoker

No

Yes

Spouse

Birth Date

Gender

Male

Female

Smoker

No

Yes

Child(ren)

Child 1 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 2 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 3 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 4 Birth Date

Gender

Male

Female

Smoker

No

Yes

Employee 5

Zip Code

Employee Name

Birth Date

Gender

Male

Female

Smoker

No

Yes

Spouse

Birth Date

Gender

Male

Female

Smoker

No

Yes

Child(ren)

Child 1 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 2 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 3 Birth Date

Gender

Male

Female

Smoker

No

Yes

Child 4 Birth Date

Gender

Male

Female

Smoker

No

Yes

* Required Fields

This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.